S 1406APPI ICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO Buu.Omc - BLRcrRICAL
BUILDING DIVISION APPLICATION/PERNUT PLUMBING, MECHANICAL.
I I. 1. TIDEN'1'IF'ICATION
Plil�lprr"°. 1406
l`1
.DING ADDRESS: $,0}�
SANT TARY NO. APPLICATION SURMII'IAL DATE
3 0 C A
NER'S NAME: PHONE
33 S S
C RACTOR:S NAME: LIC NO:
S.O
IC
CON IKOLN
ARCHITECTIENGINHER: LIC NO:-SS:
S•yo 8 �s
ESS:
s,a M V
CONTACT: PHONE
BUILDING PERMIT INT°O
BLDG E1.13CTPLUMB MECH
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
1 Inner, adman That 1 a��h Rcen.Al carer provisions nfemquer 9 (ahmmeneing
with$emion7tW)ofDavision 3efthe Business and RofeCsc'ions Cale. band mylicensc is
iofulltomemalefecr, S70�D�
Jisivemo, Clan LicO 7
QTY. ELECTRIC PERMIT 17EE
JOB DESCRIPTION
RESIDENTIAL
❑SFOWI. ❑ KITCHEN REMODEL
[:]ADDITION ❑I'LUMIIING RE -PIPE
❑STRUCTURAL
MODIFICATION
[3 INTERIOR C3 CHIMNEY REPAIR
Z
j�
)U
PERMIT ISSUANCE
gPl'LIANCCS-RIiSIDENTIAL
Dale Contractor s
jy
Z
ARCHITECCS DECLARATION
cos
Is, vd republic rerd
1 undemmnJ my plans shall bu
PANELS❑MULTI-UNIT
UP10200AMPS
p
:TilLicensed
Gherehy
U
y¢
n.]
y
4'Section7031.5
.y
CO❑1,
mNad
IMPROVEMENTSWIMMING POOLS
El BATH REMODELIRF:PAIR E] DEMOLITION
(Yfl ILR
Poure.i... I
OWNER -BUILDER DECLARATION
ufRnn that I :un exempt from the Corrine,-, License Law home
following reason. (Section 7031.5. Business and Professions Cade: Any city or county
which requires a permit to construct, alter. improve. Demolish, or repair any wuclurc
prior to its issuance. also requires the appimum fasnch pern.into lite oolinednmaueal
that he is licensed pursmmn uh the provisions office Contmcmrs Licence Law (Chapter 9
(uhmnumoing with Scotian 70,xpf 1)lvt..on3 of rim Thrinexs and Profemcions Code)m
that he is exempt Therefrom and the basis for the alleged esempeon. Any violation of
hyanyupplicam far n pennitsuhjects the nppLicantto a civil penalty of
nm marc than Five hundred dalmrs(SSW).
as owner ofthe prop:ny, ormyempinyces with wages us Theirmle mmpensaien,
will do the work, and the structure isnot amended or mTemd far sole (Set. 7044, Bwiness
Professions Cale: The Containers License Law does not apply to an owner of
property who builds or Improves thereon, and who does such work himself or through
his own employees, providerl that ach bnprovauens ata not intended or offered! for
sole. If, however. the building or impmvemcnt is sold within one yearofcompletionrhe
201-1100AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUII'NISC.
TEMP. M FUER OR POLE INET.
COMMERCIAL
EkEW BLDG/ADDITION ❑ DEMOLITION
ENANT ❑ FOOD SERVICE
❑OTHFRVLMENq
POWER DEVICES
SWIMMING POOL. CLETRIC
-
OU'TLET 'S - SINE C .: -FINE Clips
NRW RESID L rLECiR SQ FT
`
SQ. FII FLOOR ARBA
SISQ. PI'.
urhuilder will hove the burden of proving that he did not build or improve fur for,
Ipso ofwle.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors it)
A D
�141(yfAl..
construct Ne project (Sec. 704• nosiness and Prolession.x Code:) The Cunsacmr's Li-
aslawdoesnetapplytoanownerof property who builds or improves thereon, and
wbo anmmeD III, such prates whhacammucmgsl beeTucd puxeaml bile Commcmrs
�A�le
ALAR 61 Q6 ANSD
QTY. PLUMBING PHRMI FEE
PERMIT ISSUANCE
License law.
1 am exempt under Sec. . B & P C for this reason
owner nae
WORKER'S COMPENSATION DECIION
N:1'F.R-DRAIN&VENT -WATER 1137)
RACK FLOW PROTECT. DEVICE
t llV411V +%'ION
t
folio
1 herehy affirm under penalty of perjury one of dm fallowing declarations:
STORIES
TYPE CONSTRUCTION
❑Ihuve amiwill 3cae Workersccm"m
DRAINS -FL(%)R. ROOF. AREA. COND.
for by it he Lan. Code, Jurefer
workf r provided for by Section A]IXI of The Lnhnr Code, for the lnxfarmunm of The
work for which tills prmn is inucd,
FIXTURES - PER TRAP
❑Ihave and will nhuinmin Workers Compensation Insurance, as aaluired by Section
3701 ofthe labor Cade, for The Performance ofthe work for which this permit is issued.
GAS - EA. SYS 'I'FM- I INC.4 OUTLETS
OCC. GROUP
N'N
My Worker's Conhpnsation Insurance caner and Policy number am:
Carrier: Policy No :
OAS - CA. SYS"TP.M-OVER 4 (EA)
GREASMIsDOSTRL WASTE INTERCEPTOR
CERTIFICATE. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
BUILDING DIVISION PEES
(Thiswetion andoot berompleud iftheperean isdbrenehundreddollars F$I(F)
or less)
GRFASCTRAP
PLANCHECK FEE
SEWER - SANITARY - STORM EA. 200 FI'.
ENERGY FEE
I verify Thar in tM1eperfonnaneemftm work I,,, rich hills permit is 1—id.Iahn11
arsy Hens to la, rarsuhjecnothe Worker Camper-
not employ any parson
WATER I IEATI3R WNENT/CLECI'R
GRADING CEE
z
T ^
ti
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T Ili
C
T In
1'Z
-tion Lawsof l tI /
-Fphcari a - Y
NOT ICE TO API'LICANI': If, afro a mg tMs endacam of Exemption, you should
become subject m the Workers Compensation immisinns of the Lobo -Cade you nem
(onhwiTh rnmply with such provisions or this permit shall be deemed invoked.
CONSTRUCTION ].ENDING AGENCY
Thereby aflmm the, them iso comuucdon lending agency fonhc prformanceof
the work for whielamis permit is iscued(See 3097. Civ. CJ
Lendcrs Name
WATER SYSTIM?R13ATINC
WATER SERVICE
SOILS FEE
PALO
I le Neaiprp
NEW RESIDENTIAL PLMIL SQ. Ff.
1(YTAL'
TOTAL:
Irndcrs AJArces
RUILDIN F
I ceNfy that I have read this application and seta that the above information is
errect, l agree to comply with at city and county ordinances and sure laws miming to
budingennswetion, and hereby enthrone representatives ofmiscitym anter upon the
Q'I'Y. MECHANICAL PERMIT FEE
SEISMIC
PERMIT ISSUANCE
aheve-ma ntoned property for impecton purposes.
(We) ugrcu to save, indemnify uad keep Tumbles, The City of Cupninn micros
131.EC RIC PCE
PLUMBINGF
liahilitesjudgmems,cosis and expenses which may in any way accrue against said City
in asequence of the geeing of this permit.
ALTER ORADD TOMECIL
AIR HANDLING UNIT (To 111,100 CPM)
MECHANIC FEE
APPLICANT' UNDERSTANDS AND Will. COMI'1.Y WITH ALL NON-POIN)'
SOURCE REGULATIONS,
AIR HANDLING UNI'T(OVER 1(,0700 CFM)
CONS ION TAX
Signatruf Applican✓ mmetor Dae
EXHAUST HOOD fWMUCO
HOUSING ITIGATION FEE
HAZARDOUS MAI ERIALS DISCLOSURE
DRYING ON[ r(TO IWINX) BTU)
Will lheappficvnr or future building occupant noreer handle huzmdtms maerml
re do Ener by the Cutout nn Municipal Cade, Chane, 9.12, and the Health and Safety
Cade. Section 25532(x)?
I117ATING UNIT (OVER 1, JEW Er 111)
VENT] LATION FAN (SINGLE RESID)
❑Yes El No
PAID
I ReceipN
Will The applicant or future building occupant use equipment or devices which
omit hanudous air error hon a us defined by the Bay Area Air Quality Management
BOILER -COMP (HIP OR 100,00) BTU)
TOTAL
District?
❑Yes F7 No
BOILER - COMP (OVER 10,000 BTU))
AIR CONDU)ONER
ISSUANCE 06E
I have read the hazardous materials rquimrat under Chapter 695 of me Cali-
NEW RESIDPNTIN. MGCIL SQ. FI.
forma Health & Safety Cale, Sections 25505, 25533 and 25534. 1 understand that dile
building does not currently have a tenant. That it is my respmsibilaty to notify the acernion
.fine repair omenta which ..It be met prior to issuance of a Certificate of Occupancy.
TOTAL:
ISSUED BY:
Owner or aurhmaaed Nixon Date
OFFICE